Key Takeaways
- Clinical Bottom Line
- Boerhaave Syndrome: The Surgical Emergency
Clinical Bottom Line
| Component of Triad | Pathophysiological Mechanism | Clinical Presentation |
|---|---|---|
| Vomiting | Massive, uncoordinated pressure spike against a closed glottis. | Precedes the event; often alcohol-induced or related to severe bulimia. |
| Lower Chest Pain | Violent tearing of the distal left lateral esophageal wall. | Sudden, agonizing, “tearing” retrosternal pain radiating to the back. |
| Subcutaneous Emphysema | Air escapes into the mediastinum and tracks up into the neck tissue. | Physical “crackling” (crepitus) felt when palpating the patient’s cervical skin. |
Boerhaave Syndrome: The Surgical Emergency
While Mallory-Weiss tears represent superficial mucosal lacerations caused by retching, Boerhaave Syndrome is the complete, transmural rupture of a previously healthy esophagus. This spontaneous blowout almost universally occurs in the left posterolateral aspect of the distal third of the esophagus, an anatomical zone structurally devoid of surrounding supportive tissue.
The Rapid Onset of Mediastinitis
Mackler’s Triad is the classic pathognomonic presentation, though all three signs are only present in ~30% of cases. The true danger lies in the immediate contamination of the sterile mediastinum with highly acidic gastric contents and virulent oral flora. This rapidly induces fulminant mediastinitis, hemodynamic collapse, and sepsis. Endoscopy is formally contraindicated during the initial evaluation of suspected Boerhaave, as positive pressure insufflation will force massive volumes of air through the defect into the chest. Diagnosis is secured via CT scan or a water-soluble Esophagram (Gastrografin), followed by immediate thoracic surgical intervention or emergent endoscopic stent placement depending on the time of presentation.
Clinical guidelines summarized by the Gastroscholar Research Team. Last updated: 2026. This article is intended for physicians.
